Cancer treatment decision-making processes for older patients with complex needs: a qualitative study

OBJECTIVES: Although older people can experience complex health and social care needs alongside a primary cancer diagnosis, little is understood about how cancer treatment decisions are made for this population. This study aimed to investigate how cancer treatment decisions are formulated for older people with complex health and social care needs and the factors that shape these processes. DESIGN: Qualitative study involving semistructured interviews and non-participant observations. Framework approach used for data analysis. SETTING: Breast and colorectal cancer services in five English NHS hospital trusts. PARTICIPANTS: Interviews: purposive sample of 22 clinicians directly involved in a face-to-face clinical role with patients regarding cancer treatment and care, maximising variation across clinical roles, tumour types and trusts. Observations: purposive sample of five cancer multidisciplinary meetings, maximising variation across location, team size and tumour type. RESULTS: The initial stages of cancer treatment decision-making are team-based, medically dominated and focused on the cancer. For patients with complex health and social care needs that extend beyond cancer pathology, later and less visible stages in the decision-making process are more haphazard and may result in less effective and workable treatment plans, as individual clinicians struggle to devise and deliver these plans without breaching time-based targets. CONCLUSIONS: Service targets that focus resources solely on the presenting disease can disadvantage older patients with complex health and social care needs that extend beyond this primary diagnosis. Care should be taken to ensure time-based targets do not disincentivise thorough and timely assessment that can lead to the formulation of treatment plans tailored to individual needs and circumstances.